Production of primary care doctors

COGME has just released their 20th report, Advancing Primary Care. Unless you are a real geek like me, you probably don't know what COGME stands for. COGME is the Council on Graduate Medical Education. COGME was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues and financing policies, and to recommend appropriate federal and private sector efforts to address identified needs. The legislation calls for COGME to advise and make recommendations to the Secretary of the U.S. Department of Health and Human Services (HHS), the Senate Committee on Health, Education, Labor and Pensions, and the House of Representatives Committee on Commerce. The Health Professions Education Partnerships Act of 1998 reauthorized the Council through September 30, 2002. Since then, the Council has been extended through successive annual appropriations governing the Department of Health and Human Services.(1)

Now, there is some history here.  In January 1994, COGME released its Fourth report, Improving Access to Health Care Through Physician Workforce Reform. In that report the authors took the position that the physician workforce was not meeting the needs of the US healthcare system and the public need. The report concluded that we needed more generalist physicians.  Their recommendation was that 50% of all graduates should enter practice as a generalist physician (Family Medicine, General Internal Medicine, and General Pediatrics). Their goal was to attain this by 2000. As we know that did not happen. In fact, it went the other direction.

But interestingly in their Sixteenth report, Physician Workforce Policy Guidelines for the United States, 2000-2020 (2005), COGME reversed themselves and said that market forces should determine the proportion of students in an in specific specialty. The exact recommendation was: The distribution between generalists and non-generalists should reflect ongoing assessments of demand; therefore, COGME does not recommend a rigid national numerical target.  Wow, what an amazing mistake that was.  Since that time, the proportion of students choosing family medicine and primary care in general has continued a downward trend. In 2008, the total proportion was down to 32%.  Clearly market forces are not working.

Dr Jerry Kruse, Chair of Family & Community medicine at Southern Illinois University who I wrote about in a recent blog was Chair of one of the writing groups for the COGME report.  According to Dr. Kruse, market forces didn't work because there is not a traditional supply and demand market in the US healthcare system. What we have is really a supply and supply market.  We have a virtually unlimited amount of care that can be delivered (whether it should be is a different discussion) and a funding pot that rewards doctors, hospitals, DME companies, etc for doing more (See Dr. Lin's post at the Common Sense Family Doctor). The rewards are financial and huge. So, the market is designed to reward doctors financially in specialties that do more technical and procedural things. (A more detailed discussion of this can be found in a recent post by Matthews and McGinty on the Wall Street Journal Health blog.) These are specialties such as, Radiology, Orthopaedic Surgery, Anesthesiology, and Dermatology. The "ROAD", as some medical students have taken to calling it.

Medical students are not stupid. They figured out that the financial rewards of practicing in the higher paid specialties were extraordinary. The median lifetime income gap between a student choosing primary care versus a specialty is 3.5 million dollars.(2) Currently, US primary care doctors earn about 55 percent of what specialists earn on average. When primary care doctors' salaries dropped as a proportion of specialists' salaries, interest in family medicine and other primary care areas also drop. The key number seems to be around 70 percent. If the income of primary care doctors as a proportion of the income of specialty physicians goes up then student interest goes up as well. The Altarum Institute estimates that increasing primary care income to 80 percent of specialty income would double medical student interest in primary care. This would increase the percentage of students choosing primary care to about 40 percent.(3) 

Canada had the same problem. From 1998 to 2004, they had a 25% drop in students choosing family medicine and it worried the Canadian health ministry.(4)  In a country that has universal coverage, it is vital that the primary care base is adequate. In Canada, they understand and believe that they need a specific number of family doctors in order to be able to take care of the populace. To address this national crisis (their words not mine) they invested in student interest by building up and supporting medical school family medicine interest groups (FMIG).  And they raised the salary of family physicians. They did not make family medicine and specialist salaries the same, but they raised the proportion to 87%.  By 2006, the median income of Canadian family physicians was $212,000 per year compared to the median annual specialty income of $245,000.(4)  That was enough. Interest started going back up. Medical students choosing family medicine has increased by 27 percent each year since 2004.

Why can't we do that in the US? There are so many reasons that I don't think I could even begin to cover them all but let me hit some of the highlights. We don't have a national universal coverage system.  Doctors are mostly self-employed or work for large healthcare organizations (like hospitals). The government does not directly decide how much doctors are paid.  (For more on this, read Dr. Freeman's post Outing the RUC: Medicare reimbursement and Primary Care) 

The most important reason is probably that we don't see this as a national crisis.  Most people think that we have the best healthcare system in the world. Unfortunately, the data does not support that. We have a mediocre healthcare system compared to the rest of the world by any measure. The primary care base is the key to the system. We need to and should adopt the COGME recommendations. If we don't have enough primary care doctors (translate=enough students choosing family medicine), the US population will be less healthy. There is no question. Our population will be less healthy, people will die prematurely, and it will cost more.(5)

References
(1) http://www.cogme.gov/whois.htm
(2) Wilder V, Dodoo MS, Phillips RL Jr, Teevan B, Bazemore AW, Petterson SM, Xierali I. Income disparities shape medical student specialty choice. Am Fam Physician. 2010 Sep 15;82(6):601
(3) Altarum Institute. (2009). Updates to BHPR phy­sician supply and requirements models. Presenta­tion to COGME, p. 15. Rockville, MD, from COGME 20th report
(4) Canadian Institute for Health Information. (2007, December 13). Physicians in Canada: Average Gross Fee-For-Service Payments, 2005-2006. Re­trieved May 11, 2010, from http://secure.cihi.ca/ cihiweb/products/FTE_APP_2005_Eng_final.pdf
(5) Phillips RL Jr, Bazemore AW.  Primary care and why it matters for U.S. health system reform. Health Aff (Millwood). 2010 May;29(5):806-10

Using interviews to select medical students

This is the fourth in a series of posts about entry of students into medical school. In the last post, I blogged about personality traits that may be better suited to being a medical student. Unfortunately, most schools in the US do not use personality profiles as a screen for incoming medical students.

At most schools, the closest that we come to this is the admissions interview. Many believe that a 30 minute interview is a good way to weed out bad apples. I am not sure that this is true. Just on the surface, it seems like an experienced interviewer may be able to identify highly dysfunctional people. By dysfunctional, I mean traits that would be obviously detrimental to their function as a physician. These obvious dysfunctional traits are things like: students who have difficulty talking to others, students who have flaws in their ethical approach to life, and students who have problems with their reasons for entering medical school. But what does the literature say?

Powis, et al (1) used a case-control design to study students who were admitted to medical school but did not graduate. They retrospectively analyzed 56 paired cases and controls. The cases were students who had left medical school due to failure or withdrawal, while the controls were students who had completed medical school. The controls were all students who had excelled in the their academic performance. The students who left medical school had all been rated lower at their admission interview. Effect sizes were statistically significant in the Overall rating (ES=2.17), self-confidence (ES=2.59), perseverance (ES=2.98), and tolerance of ambiguity (ES=1.04).

The Powis study used a objective and structured interview and they compared the students who left or were dismissed from medical school to those who received Honors in medical school. It is not clear that the admission interview would distinguish between failing students and anyone who would not fail. Admission interviewers have widely variable reliability. Powis found the inter-rater reliability varied from .23 to .63 for seven different qualities assessed by two faculty members. Other studies have found that reliability data is better for interview programs that use a structured interview process (.82 to .84) while with unstructured interviews the reliability is .61 to .75. (2)

So, reliability is not great, but seems to be better with more structure. Part of what provides structure is giving interviewers training and giving them types of questions to ask. But (and this is a big but)...I think that the interviewer has to be experienced as an interviewer. They have to be able to sort through the information presented by the student. They have to be willing to ask probing questions and be willing to make the student uncomfortable. Questions about ethical grounding or hypotheticals about decision-making are difficult. Interviewers can be blinded by other characteristics. Like MCAT scores．

For instance, I have heard interviewers say, well they didn't interview very well but they have great MCATs, so they will do fine. I am not kidding, I really heard a faculty member say that. And they were being serious! I know that is not supported by the data, but you still hear it a lot. The interviewer has to be experienced enough to ask tough questions. Not just, "tell me about your fraternity activities in college" but hard questions about ethics, hypotheticals, and dilemmas. They have to ask about motivation, why do they want to come to medical school. They have to get beyond the pat and prepared responses that students practice during their mock interviews and really push the student to get at internal motivations and thought processes.

And what about medical students? In my experience the medical students that we ask to interview are pretty good at sniffing out the bull. But their problem is that they feel so happy to actually be in medical school and almost finished (our interviewers are fourth year students) that they tend to be a little easy on the score sheets. Gutowski and colleagues,(3) looked at current medical student interviewers. They found that when compared to faculty interviewers, students wrote more about applicants' motivation, personality, communication skills, and interests. Student wrote more in the overall evaluation sections (p<0.001) and gave more examples on the motivation section (p<0.0011) and communication skills section (p<0.0035).

So, I guess the bottom line is that there is no easy way to figure out who are the right students to admit to medical school. We should push for multi-dimensional models that minimize the MCAT and utilize personality characteristics. We should ask the admissions committee (and the dean) to define what they think are the qualities and characteristics of the students that should matriculate to our medical school. And maybe most importantly the admissions committee should be held responsible for the results of their work.

References
(1) Powis DA, Neame FLB, Bristow T, Murphy LB. The Objective Structured Interview for Medical Student Selection. BMJ. 1988;296:765-768.
(2) Albanese M, et al. Assessing Personal Qualities in Medical School Admissions. Acad Med 2003;78:313–321.
(3) Gutowski CJ, et al. Current medical student interviewers add data to the evaluation of medical school applicants. Medical Education Online 2010;15:5245.

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